Long-Term Care Policy Summit

Suzanne CrispDirector of Program Design & ImplementationBoston College

Today’s Discussion

Balancing Incentive Program Community First Choice Option

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Balancing Incentive Program Purpose – Encourage States to rebalance

budgets Shift Medicaid dollars from institutions to the

community Enhanced FMAP to increase diversions and

access to HCBS 5% if less than 25% LTSS spending in non-

institutional settings 2% if less than 50% LTSS spending in non-

institutional settings Enhancement ends after two years

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Requirements

Aging and Disability Resource Centers (ADRC) Single point entry or no wrong door -

Uniform assessments process Eliminate conflict of interest

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Conflict Free Case Management Desire of CMS for years Eliminate:

Incentives for over or under utilization Retain as clients through failure to promote

independence Focus on agent or provider convenience rather

than person-centered practices Independent agent should not be influenced

by variations in local or State funding Service plan based on needs-based criteria

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Conflict Free Case Management Independent assessments and service plan

development may not be performed by a provider that will then provide services

Payment to the provider of services for evaluation and assessment cannot be based on the cost of the resulting plan of care

In rare instances, service providers may evaluate and assess but firewalls must be present

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Section 1915(k) Community First Option Section 6078 of the Affordable Care

Act 2010 Provides vehicle to use consumer

control to provide personal assistance services

Consumer control Individual exercises as much control as

desired to select, train, supervise, schedule, determine duties, and dismiss the attendant care provider

Community First Choice Option Attendant services & supports to assist in

accomplishing activities of daily living (ADLs), instrument ADLs, and health-related tasks through hands-on assistance, supervision, or curing

Back-up System must be in place Transitions costs required Allows for the provision of services that

increase independence or substitute for human assistance to the extent that expenditures would have been made for human assistance

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1915(k) Recognizes Three Models

Agency-provider model Entity contracts to provide services directly through

employees or arranges for the services under the direction of the individual

Agency acts as the employer of record Individual must have significant and meaningful role in

management of services Self-directed model with service budget

FMS must be available Reimbursed at service or administrative FMAP rate Cash or vouchers permitted Participant is employer of record

Other service delivery model States may propose other models

Support Services Required

Operate with person-centeredness Provide support system

Assesses and counsels Provides information Includes information on risks and

responsibilities including tools Develops a backup plan Assessors are free from conflict Data collection

Section 1915(k) May offer goods and services Home modification excluded unless tied to

increased independence or sub for human asst.

Targeting not permitted Must offer statewide Current activity – CA, MN, AK, NY, AZ Differences between the (j) and (k)

Enhanced funding (k) Level of Care (k)

Section 1915(k) Continued Allows a cash benefit Prospective payments allowed Target population must meet level of care FMS reimbursed at service or admin rate Requires creation of a Development and

Implementation Council Enhanced FMAP at 6% Requires a face-to-face assessment

(telemedicine) annually Person-centered planning required

The Possibilities

Include all participant directed program under one authority that offers enhanced match

Replace State Plan Personal Care and Waiver Attendant Care with Community First Choice and receive Enhanced Match (6%)

Section 1915(i) Targets those not meeting LoC

Use FMS Support Structure to Manage all PD

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Challenges of Community First Choice Create sufficient supports to ensure

program integrity Case Management, care coordination and

self-directed counseling –YIKES! Establish and maintain a comprehensive

continuous quality assurance system Collect and report information for Federal

oversight and the completion of a Federal evaluation

Serves a LoC population only

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Challenges of Community First Choice Option Must receive one waiver service to

maintain financial eligibility Consumer Control – how broad, how

narrow Coordinating assessment and service

planning with other authorities Who has final say in care coordination?

Waiver case manager Targeted case management Health Home coordinator

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Majority of States have more than one Participant-Directed LTSS

Program

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States with less than 1,000 PD articipants

States with 1,000 but less than 5, 000 PD articipants

States with 5,000 but less than 10, 000 PD articipants

States with more than 10, 000 PD articipants

Majority of States have 1000 – 5000 Self-Direction LTSS Participants

WAAK

OR

CA

NV

ID

MT

WY

UT

AZ

CO

NM

TX

OK

KS

NE

SD

ND MN

IA

MO

AR

LA

MS

TN

KY

IL

WI

MI

INWV

AL GA

FL

SC

NC

VA

PA

NY

DC

MD

DE

NJ

RI

MA

NH

VT

ME

OH

CTHawaii

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Traditional Services

Participant-Directed Services

Positive Impact of Life

Cash & Counseling participants were up to 90% more likely to be very satisfied

with how they led their lives.

Assessed Needs Met

Cash & Counseling significantly reduced participants’

unmet personal care needs.

Caregivers Better Satisfied

Primary caregivers were significantly more satisfied with their

lives in general.

Virtually No Fraud or Abuse

Cash & Counseling did not result in the increased misuse of Medicaid

funds or abuse of participants

Essential Elements of Participant Direction Person-Centered Practices Individual budget Information, Assistance and Supports Financial Management Services

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Commonly Used TermsParticipant-Directed Counselor: Individual who works with the participant in designing their plan. The person the participant goes to with questions.

McInnis-Dittrich, Simone, and Mahoney (April, 2006)

Understand Federal Employment Obligations Internal Revenue Services – uniform across states Payroll for participant-directed services is different Separate Employer Identification Number required? Are guidelines clear for completing forms, filing,

withholding, and depositing If reconciliation is necessary – can you perform this? A few forms: IRS Forms – 940, 941, 2678, W-3, W-

4, 1099, 1096 When are numbers retired? How do you calculate Federal unemployment taxes?

When do you deposit? How do you manage overpayments of SSA and

Medicare Taxes

Common Findings – Self Direction Rebalances Service Dollars Acute care and high costs services are lower

for those self-directing, however, basic service costs increase

Per capita Medicaid costs are less for self-directed participants than traditionally served participants

Costs per hour are lower for those using self-direction than for agency services

If the cost of counseling and FMS are considered in the design of the program, these are at least neutral

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Tangible Costs Considerations Hiring family members – reduce

unemployment or public assistance Income tax implications Service costs – Participants receive

services Case management – add on – PD in addition

to CM tasks Financial Management Services Admin staff to run a PD program – cost vs

efficiency

Intangible Considerations

Satisfaction/Safety with PD QOL impacts health – health impacts $ Responsibility and authority can lead to

good stewardship Caregiver satisfaction

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Contact Information

www.suzanne.crisp@bc.edu

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